health essay

Breastfeeding Is A Growing Infants Best Food Source Health Essay

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This chapter presents the background and significance of this study, research question, objective, theoretical framework, definition of terms, and anticipated outcomes and benefits.

Incomparable, breastfeeding is a growing infant's best food source. Playing an important role in a mother's reproductive process and health, breastfeeding comes highly recommended by the World Health Organization. Ideally, exclusive breastfeeding will occur during the initial first six months of a human's life to ensure the very best possible health implications (WHO, 2002). Apart from a limited number of health concerns, exclusive breastfeeding means a plentiful supply of milk. Not only do infants suffer from less illness as a result of gastrointestinal infection, babies exclusively breastfed for half a year displayed zero concern relating to physical development. Moreover, the mother possesses a higher disposition to amenorrhea throughout half a year following giving birth (Kramer & Ritsuko, 2009).

During the period between 1995 and 2010, statistics show that the average percentage of exclusive breastfeeding until 6 months was 36.3% (UNICEF global databases, 2011). Meanwhile, in Indonesia, exclusive breastfeeding rates were decreased inversely to baby's ages. Exclusive breastfeeding rates in the first month of a baby's life were 39.8% and decreased dramatically to 15.3% in the first five month of a baby's life (Riset Kesehatan Dasar, 2010).

Yogyakarta province is one of leading cultural center of Java islands. It has four regencies and one municipality that is Yogyakarta municipality, the smallest area with the highest population. Most of immigrants from other provinces stay in Yogyakarta Municipality. In 2010, exclusive breastfeeding rates in Yogyakarta province were 40.57%. In more detail, exclusive breastfeeding rates in Yogyakarta municipality is the lowest in Yogyakarta province, were about 20-39%. Furthermore, there is a great distance to attain 80%, the target stipulated by the government for exclusive breastfeeding (Yogyakarta Province Ministry of Health, 2011).

Exclusive breastfeeding until 6 months is the way to obtain the best babies and mothers' health. In addition, the result of previous study conducted by Ladomenou (2010) gives a result that babies who got non exclusive breastfeeding have more frequent for hospital admission because of any infection diseases (OR 0.980, 95% CI 0.961 to 0.999, p = 0.036). Moreover, not breastfeeding babies have more risk for diarrhea incidence (RR 2.65), partial breastfeeding (RR: 1.68), and predominant breastfeeding (RR: 1.26) (Lamberti, 2011). Furthermore, breastfeeding help mothers to decreases postpartum blood loss and have uterine involution rapidly due to oxytocin secreted (Naylor, 2009). In agreement with the WHO recommendation, UNICEF promotes exclusive breastfeeding to recover of children's lives in Indonesia. Moreover, the Indonesian government estimates that a part of 30,000 children could salvage from under nutrition, morbidity and mortality regarding under nutrition condition if they got exclusive breastfeeding until six months from their mothers and then continued breastfeeding with supplemental foods within two years of life (UNICEF, 2006).

Factors related to exclusive breastfeeding until 6 months could be classified to maternal and environment factors. One of difficulties to actualize exclusive breastfeeding could arise from infant formula advertisements which are difficult to control. Many hospitals do not support an exclusive breastfeeding program with no implementation of a rooming-in program for postpartum mothers and their babies. Moreover, some also provide infant formula for every patient that has gone through the labor process within their hospital (Indonesian Ministry of Health, 2011).

Moreover, the factors regarding 6 months exclusive breastfeeding explained by the research findings conducted by Tan (2011) that exclusive breastfeeding among first six months infants in Peninsular Malaysia were significantly correlated to some socio-demographic characteristics, include area of residence, maternal ethnicity, occupation, smoking status, parity, infant gestational age, husband support on breastfeeding, and bed-sharing practice. In more detail, mothers from rural area were more possible to breastfeeding exclusively than mothers from urban area (OR= 1.16; 95% CI: 1.03,1.89), Chinese mothers were less likely to exclusive breastfeeding than Malay mothers (OR = 0.20; 95% CI: 0.11, 0.35), non-working mothers were more likely to exclusive breastfeeding (OR = 3.66; 95% CI: 2.45, 5.46), not smoking mothers were five times more possible to exclusive breastfeeding (OR = 5.18; 95% CI: 1.59, 45.05), and multiparous mothers were more likely to exclusive breastfeeding than primiparous mothers (OR = 1.68; 96% CI: 1.17, 2.42). In addition, mothers with term babies more likely to exclusive breastfeeding (OR = 1.74; 95% CI: 1.05, 3.01), mothers who got support on breastfeeding from their husbands were five times more possible to exclusive breastfeeding (OR= 4.20; 95% CI: 1.12, 15.75), and mothers who sharing their beds with their babies were more possible to exclusive breastfeeding practice (OR = 1.50; 95%CI; 1.12,2.37). In addition, the result of a cross-sectional study conducted in Western Tanzania by Nkala and Msuya (2011) gives information that mothers with any breast's problems during first six months were less likely to exclusive breastfeeding practice than mothers without breast's problems (OR= 0.14; 95% CI: 0.07, 0.26).

Similarly, mothers who have labor process at home were more possible to breastfeeding their infants exclusively than mothers who have labor process in hospitals (OR = 9.13; 95% CI: 4.24, 11.98) and mothers with vaginal delivery were more likely to breastfeeding exclusively than mothers with Cesarean section (OR = 1.31; 95% CI: 1.38, 2.44) (Al-Sahab et al, 2010).

A mother's perception that exclusive breastfeeding have advantages to their babies' health was drive them to give breastfeeding exclusively. Besides, their perception and practice in exclusive breastfeeding influenced by their knowledge related to exclusive breastfeeding (Petit, 2010). Moreover, mothers' perception of the benefit of exclusive breastfeeding has a relationship with exclusive breastfeeding practice (Uchendu, 2009). The pilot study conducted by the researcher in March 2012 found that one of a mother's reasons to stop exclusive breastfeeding practice is the lack of knowledge related to breastfeeding. For example, "When I had pain in my breast, I was chosen to stop breastfeeding because my mother said that breast milk from the breast while experiencing pain is not good for my baby", this was one participant's reason to stop breastfeeding before the end of the first month of the breastfeeding period. "I know breastfeeding is good for my baby, but my breast milk run out after my baby drank it"

A previous research conducted by Otoo (2008) provides information that barriers to exclusive breastfeeding were come from maternal, infant, and socio cultural factors. Maternal factors such as mothers have to go to work, breast problem, and mothers' perception of inadequate breast milk. In addition, infant's health problem and difficulty to latch and suck are the barriers to breastfeeding exclusively as infant's factors. Moreover, mothers' feeling embarrassment to breastfeed in public also one of barriers to breastfeeding exclusively.

A study was conducted in Indonesia provides information that the most reason not to give exclusive breastfeeding until 6 months is their perceived insufficient breast milk supply. Other reasons are their belief that the baby was starving, mothers has activity outside their home, poor knowledge of the benefits of exclusive breastfeeding and mother's illness. However, breast milk is supply and demand. When the mother believes that she do not have enough breast milk supply, they will decrease their frequency to breastfed and give formula or complementary food for their baby. This will give effect to the decreasing of breast milk production. "I am sure that I did not have sufficient breast milk production. My breast milk is too small and I am too thin as well. My mother in law said that this child (pointed out her two year old son), was too thin when he was an infant, although I had already given my breast milk to him. Therefore she said to me that I should give him other foods as he was three months old" (Inayati. D. A et al, 2012).

A mother's self efficacy in breastfeeding has a significant bearing on exclusive breastfeeding intention. Mothers who intended to breastfeeding exclusively had higher self-efficacy score than mothers who intended to breastfeeding partially (t(252)= 4.99, p<0.001) (Otsuka et al, 2008). The pilot study conducted by the researcher also found that mother's low self-efficacy in breastfeeding is one reason not to continue breastfeeding practice exclusively, "I know exclusive breastfeeding is good for my baby, but I was not sure whether I could do it or not".

The father's role as a part of a breastfeeding team in a breastfeeding family was an important factor influencing mothers in decision making and breastfeeding practice. Fathers could support breastfeeding mothers using their knowledge to embolden and help mothers during the breastfeeding period by giving appreciation to their partner, sharing in housework and taking care of their children (Rempel & Rempel, 2010). Furthermore, the research findings conducted by Kupratakul (2010) gives information that antenatal and postnatal support from health professional as knowledge sharing practice with empowerment strategies could increase exclusive breastfeeding rate until six months in experimental group significantly (20% versus 0%, p= 0.005).

According to Pender (2006), the human being's capability of knowledge, self-regulation, decision making, and problem solving give an individual the potential for self-change. A new behavior that a client is willing to achieve is the definition of self-change. Furthermore, Health Promotion Model's framework could give guidance to explore the biological, psychological, and social processes that motivate people to engage in specific health behavior to foster health improvement.

There are some previous studies related to breastfeeding conducted by Health Promotion Model (HPM) as a theoretical framework. Prior related behavior, personal factors, perceived benefits of action, perceived barriers to action, perceived self-efficacy, activity related affect which directly or indirectly through self-efficacy, interpersonal influence (family, peers, and health professional) and situational influence which close to environment condition of HPM has been reported in the reference to promote initiation and duration of breastfeeding. Additionally, exclusive breastfeeding is one example of health promotion to increase human well being within a holistic human functioning perspective regarding HPM theoretical basis. Besides that, one literature review study of breastfeeding as health promoting behavior for Hispanic women conducted by Schlickau and Wilson (2004) provides information that HPM is a suitable framework to the determinants of breastfeeding. Moreover, HPM also could help to develop interventions to promote breastfeeding. However, from the literature review, several studies and report did not clearly define exclusive breastfeeding. Moreover, a lot of study about factors related to breastfeeding but only a few study about factors related to exclusive breastfeeding. Furthermore, there is little information regarding specific social and cultural factors influencing breastfeeding practice in Indonesia, particularly in Yogyakarta province. In order to fill in the gap of the factors related to exclusive breastfeeding practice among mothers within the first six months of a baby's life, this study intends to describe the factors related to exclusive breastfeeding practice among mothers within the first six months of a baby's life in Yogyakarta Municipality, Republic of Indonesia. Regarding factors related to breastfeeding using HPM items as theoretical framework, the factors related to exclusive breastfeeding practice among mothers within the first six months of a baby's life in this study will focus on individual characteristics and experiences, perceived benefits of action, perceived barriers to action, perceived self-efficacy, interpersonal influences and situational influences.

Research question

What are the factors related to exclusive breastfeeding practices among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia?

Specific research questions include:

Are individual characteristics and experiences of mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia related to their exclusive breastfeeding practice?

Are perceived benefits of exclusive breastfeeding among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia related to their exclusive breastfeeding practice?

Are perceived barriers of exclusive breastfeeding among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia related to their exclusive breastfeeding practice?

Is perceived self efficacy of exclusive breastfeeding among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia related to their exclusive breastfeeding practice?

Are interpersonal influences of exclusive breastfeeding among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia related to their exclusive breastfeeding practice?

Are situational influences of breastfeeding among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia related to their exclusive breastfeeding practice?

Objective of this study

The objective of this study is to describe the factors related to exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

Specific objectives of this study include:

To examine the relationship between individual characteristics and experiences and exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

To examine the relationship between perceived benefits of exclusive breastfeeding and exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

To examine the relationship between perceived barriers of exclusive breastfeeding and exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

To examine the relationship between perceived self efficacy of exclusive breastfeeding and exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

To examine the relationship between interpersonal influences of exclusive breastfeeding and exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

To examine the relationship between situational influences of exclusive breastfeeding and exclusive breastfeeding practice among mothers within the first six months a baby's life in Yogyakarta Municipality, Republic of Indonesia.

Scope of the study

This study will be conducted on mothers who have babies within the first six months of life and visit the maternal and child policlinic at one district hospitals and three primary health centers in Yogyakarta Municipality, Republic of Indonesia.

Theoretical framework

Although the knowledge related to exclusive breastfeeding increasingly, exclusive breastfeeding rates in Indonesia particularly in urban area were low. Mother's belief that infant formula is better than their breast milk is one of reason for the mother to give infant formula early. Moreover, based on International Code of Marketing of Breast milk substitutes, the Indonesian code prohibits free distribution of infant formula by the producer to the health provider as well as to the mothers, but does not have a specific rule as prohibits or not health providers and facilities provide infant formula for free or at cost to the mother (DePee. S et al, 2002). No implementation of rooming in program also one example of lack of support for exclusive breastfeeding practice from health service (Indonesian Ministry of Health, 2011). Furthermore, fathers and family perception that breastfeeding is mothers' business also exist in Indonesian society.

Synthesizing the breastfeeding situation in Indonesia, Health Promotion Model (HPM) developed by Pender in 1982 to explain and predict a population's health promoting behavior will appropriate to give guidance to this current study. The model was revised in 1987 and revised again in 1996. The revised model of HPM 1996 will be used in this study as a theoretical framework to guide the assessment process of exclusive breastfeeding practice and explore the factors related to exclusive breastfeeding practice among mothers within the first six months of life because Health Promotion Model's framework could give instruction to explore the biological, psychological, and social factors that encourage people to implement in specific health behavior to maintain health improvement.

In accordance with Pender, variables in the HPM revised in 1996 include individual characteristics and experiences of prior related behavior and personal factors; behavior-specific cognitions and affect include perceived benefits of action, perceived barriers to action, perceived self efficacy, activity related to affect, interpersonal influences, and situational influences. Moreover, the following are also contributions, immediate competing demands and preferences, commitment to plan of action and health promoting behavior with behavioral outcome.

Furthermore, there are 2 factors which support health promoting behavior, that are individual characteristic and experiences and behavior specific cognition and affects. In more detail, individual characteristics and experiences consist of two variables; prior related behavior that have direct and indirect effects on engaging of health promoting behavior respecting of past behavior may due to habit rhythm. Besides, the personal factors which relevant to the specific behavior predict the behavior frame by the nature of the target behavior being interpreted. However, some personal factors cannot be changed. On the contrary, the second factors which support health promoting behavior is behavior specific cognition and affects that are consist of perceived benefits of action, perceived barriers to action, perceived self-efficacy, activity related affects, interpersonal influences and situational influences are more important to modify the motivation to engage in health promoting behavior.

According to the literature review, individual characteristics and experiences of prior related behavior and personal factors in this study will focus on the mother's age, educational level, ethnicity, work status, parity, physical condition, labor method, labor place, breastfeeding plan, family income, baby's physical condition, and duration of exclusive breastfeeding practice in particular relation to Pender (2011) that the frequency of the same or similar experience in the past is the best predictor of future behavior and personal factors were described as biological, psychological and socio-cultural.

In addition, mothers' knowledge regarding the benefit of exclusive breastfeeding for their babies may consistent with perceived benefit of action in Pender's Health Promotion Model. While, the lack of knowledge related to how to maintain exclusive breastfeeding may compatible with perceived barriers of action and mothers' perception about insufficient breast milk may conformable with perceived self-efficacy in Pender's Health Promotion model. Moreover, support from their husbands, parents, social and environment are frame of interpersonal and situational influence in exclusive breastfeeding practice.

Individual characteristics and experiences

Behavior-specific cognitions and affects

Behavioral outcome

Prior related behavior

Prior breastfeeding experience

Personal factors

mother's age

educational level

ethnicity

work status

parity

physical condition

labor method

breastfeeding plan

family income

baby's physical condition

duration of exclusive breastfeeding practice

Perceived benefits of exclusive breastfeeding

Perceived barriers of exclusive breastfeeding

Perceived self-efficacy in exclusive breastfeeding

Interpersonal influences in exclusive breastfeeding

Situational influences in exclusive breastfeeding

Exclusive breastfeeding practice among mothers who have babies within the first six months of life

Definition of terms

Theoretical definition: Individual characteristics and experiences a unique personal information that affects and could predict personal behavior in the future (Pender, 2006).

Operational definition: Individual characteristics and experiences in this study describe the personal characteristics and experiences of mothers within the first six months a baby's in Yogyakarta Municipality assessed through the interview form developed by the researcher.

Perceived benefits of action

Theoretical definition: Perceived benefits of action are expected outcomes as a result of engaging in a specific health behavior (Pender, 2006).

Operational definition: Perceived benefits of action in exclusive breastfeeding are the expectation of positive outcomes that will result from exclusive breastfeeding practice as assessed through the questionnaire form developed by the researcher based on perceived barriers to exercise developed by Scherist (1985).

Perceived barriers to action

Theoretical definition: Perceived barriers to action are affectively intentions to engage in a specific health behavior and to execute that behavior (Pender, 2006).

Operational definition: Perceived barriers to action in exclusive breastfeeding are perceived as preventing exclusive breastfeeding practice while negative outcomes are beliefs that will result from the behavior as assessed through the questionnaire developed by the researcher based on perceived barriers to exercise developed by Scherist (1985).

Operational definition: Perceived self efficacy in breastfeeding is a mother's opinion of her ability to manage the condition and situation to give breastfeeding as assessed by the Breastfeeding Self Efficacy Scale (BSES) short form developed by Dennis (1999).

Interpersonal influences

Theoretical definition: Interpersonal influences in Pender's Health Promotion Model are family, peers, and health care professionals. In addition, interpersonal influences include the significant person's expectations, instrumental and emotional support from their social network, and role models as a learning source by observing other people who realize a specific health behavior (Pender, 2006).

Operational definition: Interpersonal influences in exclusive breastfeeding practice are help, motivation, and support from family members, peers and health providers to engage in exclusive breastfeeding behavior as assessed by the interpersonal influence questionnaire developed by Rhonda (2011).

Situational influences

Theoretical definition: Situational influences are personal perception and awareness of any situation or context which facilitate or obstruct a behavior (Pender, 2006).

Operational definition: Situational influences affecting exclusive breastfeeding are mother perception and awareness of any environmental situation and condition which make it easier or more difficult to engage in exclusive breastfeeding practice as assessed by Rhonda (2011).

Anticipated outcomes and benefits of the study

Anticipated outcomes and benefits of factors related to exclusive breastfeeding practice among mothers within the first six months of a baby's life in Yogyakarta Municipality are as follows:

Factors related to exclusive breastfeeding practice among mothers within the first six months of a baby's life in Yogyakarta Municipality will provide in-depth information of factors which are related to exclusive breastfeeding practice in Yogyakarta Municipality.

The outcomes of this study could be used as a base of information that will be benefit to health professionals in developing programs or interventions to increase breastfeeding practice in Yogyakarta Municipality.

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